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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST AOZ-,DJ-z243 <br /> Type of Business or property FACIUTYIO f SERVICE REQUEST f <br /> Al D -T FA002306 S�ds72 <br /> OWNER/OPERATOR <br /> I �. �-1-I�— CrraacH&un+G aooREetL`t , <br /> Fwer NnME L C <br /> anCA t' I <br /> SffE ADDRESS <br /> c��++�o�t7v qS !I <br /> I s pip ow Dsa � � <br /> HOME or MAR)NG ADDRESS (r Different from Site Addraas) <br /> e <br /> CITY STATE LP <br /> WI IC <br /> PHONE#1 rpm LANG Use APPLICATIONa <br /> PHONE i2 2 BOS DurmcT L=Ar*N Coot <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR CNECKIt&LUNO A00REss❑ <br /> .BuslNEss NAME pHom") an. <br /> Home or MAILING ADDRESS FAX f <br /> CITY STATE LP <br /> SUNG ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project Or <br /> actlAty will be billed to me or my busyness as Identified on this forth. <br /> I also certify that I have prepared this application and that the work to be performed will be done In accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codas,Standards,STATE and FEDE <br /> APPLICANTS SIGNATURE: DATE: L 1211 ZOIh <br /> PROPERTY I BUSINESS O NIIR� Ore /MANAGER 13 OTNERAUTNoarzeo AoeNT 13 <br /> . . IfAPPUrArrr Is not the JXWG PARTY,proof of authorization to sign/s required Tine <br /> AUTHOR¢ATION TO RELEASE INFORMATION; When applicable, I,the owner or operator of the property located at the above <br /> site address,hereby surrodze the release of any and all results,geotechnical data and/or em ironmentaltsite assessment Information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT es soon as it Is available and at the same time It Is provided to n <br /> r <br /> my representative. <br /> TYPE OF SERviCE REQUESTED: y/vF�T <br /> COMMENM <br /> ACCEPTED Sr. � EMPLOYEE 0: DATE: 'a _) <br /> AESlehra TO: EMPLOYEE f: DATE: k. ^T '/i <br /> Date Service Completed f already Completed): SERVICE CODE: 0 PIEo��d J <br /> Fee Amount: � Amount Pa ��j,b� Payment Data <br /> Payment Type yInvoice A Ch d O��Q.� Reeeived B . <br /> EHD 4"2-025 SR FORM(Golden Rod) <br /> W/17/Da <br />